Prefer to email or post? Would you prefer to email us or send us a letter by post? If so, click the button below to download a Microsoft Word version of the referral form which can be attached to an email or sent to us by post. Download Form Referral Form Client 1 Name (required) Address (required) Telephone number (required) Email (required) Date of Birth Relationship to child Client 2 Name Address Telephone number Email Date of Birth Relationship to child Child(ren)'s Details First Name Surname Name Gender MaleFemale MaleFemale MaleFemale Date of Birth Issues for mediation? Child issuesProperty & FinanceAll Issues Does the client(s) have any special requirements (e.g. Wheelchair access, interpreter, health issues)? Any other information or details of which you think we should be aware? Privacy note - Please note that by completing this referral form you are giving consent to Mediation Associates to hold limited personal information in order to enable you to get access to the mediation information and assessment process introduced by the Children and Families Act 2014, s 10). This information will be held securely and will only be used for the purpose of providing information or mediation and where appropriate securing legal aid. You can request your data be removed from our systems by contacting us in writing.